Bleeding to death from cut K2: a case of synthetic marijuana induced coagulopathy

Introduction: There has been a major increase in synthetic marijuana use in recent times as it considered a “safe” alternative to cannabinoid use. Unfortunately, as the composition is unknown, so are the side effects. We are presenting this case to bring awareness for one of the many life threatening side effects of synthetic marijuana use. Case Description: Our patient is a 41 year old female presenting with hematuria, menorrhagia, and spontaneous bruising. She endorsed use of ‘K2’ synthetic marijuana (SM) four days prior to onset of symptoms. She denied any medications or history of coagulopathy. Initial labs revealed hemoglobin 4.2 g/dL (baseline: 10 g/dL), PTT: 175 seconds (25-35 seconds), and undetectable INR. CT abdomen did not show hemorrhage. With recent K2 use and signs and symptoms consistent with coagulopathy, our concern was for contaminated K2. Anticoagulant poisoning panel was positive for brodifacoum. She was treated with FFP, PRBCs, oral and IV vitamin K. INR improved to 1.7, PTT 45. Patient was discharged on Vitamin K 10 mg three times daily. Discussion: The incidence of SM contamination leading to life threatening coagulopathy has only recently been identified. Little is known regarding the composition of SM or mechanism leading to coagulopathy. However, brodifacoum has been implicated as the culprit. This compound acts by inhibiting vitamin K epoxide reductase and is 100x more potent than warfarin. Half-ife is between 20-150 days and symptoms can present up to three months after use. Presenting symptoms can include epistaxis, melena, menorrhagia, and spontaneous intracranial hemorrhage. Labs will reveal elevated INR, prolonged PTT, and acute anemia. An anticoagulant poisoning panel is necessary to confirm presence of toxins. Treatment includes FFP or prothrombin complex concentrate with vitamin K. Duration of therapy is undetermined, but may be more than 6 months of oral vitamin K. Conclusion: Maintain a high index of suspicion for brodifacoum poisoning with new onset coagulopathy. Treatment include FFP, repeated, high dose vitamin K supplementation while simultaneously contacting poison control. Patient education is of upmost importance

Running and rapping our way to wellness: internal medicine residency approach to preventing burnout

Background: Physician burnout has led to increased cardiovascular disease, shorter life expectancy, problematic alcohol use, depression, and suicide. A recent meta-analysis on burnout and patient experience highlighted the strong association between physician wellness and the quality of patient care. Unfortunately, burnout in internal medicine ranks among the highest of all specialties, with rates up to 76%. Purpose: To facilitate resident mental and physical well-being through initiatives focused on supportive colleague relationships and exercise. Methods: We implemented two related interventions. 1) RAPS (Resident Advisor for Peer Success) is a structured peer advisor program for incoming interns to jump-start a “connection” with their continuity clinic team shortly after match day. This early and sustained contact provides interns with an immediate resource for questions/support and ongoing connections with senior residents and a faculty advisor. 2) Fit4Life intervention continued to build/ support colleague relationships through personal fitness. Wellness challenges between trainee years were held to promote physical health per American Heart Association (AHA) exercise guidelines. Three measures — a Fit4Life survey, semi-structured interviews with interns, and Mayo Well-Being Index (MWBI) — were used to evaluate process and outcomes. Results: Fit4Life pre-, during, and postchallenge data showed that less than 20% of internal medicine residents met AHA guidelines: 150 minutes/week of aerobic physical activity. Challenge period results showed a modest but not significant increase in exercise. Average completion rate was 83% of internal medicine residents. Exercise, per AHA recommendations, was paired \u3e50% of time with another activity (eg, watch/listen to television, movies, music, podcasts; connecting with family/friends). RAP intern interviews (13 of 13 [100%]) revealed that 85% were supportive of RAPS and 100% met weekly with RAPS team member(s) at continuity clinic. MWBI scores throughout intervention were well below instruments established at risk level for burnout (5.0), with below burnout scores ranging from 3.1 preintervention (February 2018) to 2.3 postintervention (December 2018). Conclusion: The results of our well-being interventions focused on supportive colleague relationships through RAPS and exercise reveal high participation rates and support but no significant impact on physical or mental health as measured by Fit4Life and MWBI

Running and rapping our way to wellness: internal medicine residency approach to preventing burnout

Background: Physician burnout has led to increased cardiovascular disease, shorter life expectancy, problematic alcohol use, depression, and suicide. A recent meta-analysis on burnout and patient experience highlighted the strong association between physician wellness and the quality of patient care. Unfortunately, burnout in internal medicine ranks among the highest of all specialties, with rates up to 76%. Purpose: To facilitate resident mental and physical well-being through initiatives focused on supportive colleague relationships and exercise. Methods: We implemented two related interventions. 1) RAPS (Resident Advisor for Peer Success) is a structured peer advisor program for incoming interns to jump-start a “connection” with their continuity clinic team shortly after match day. This early and sustained contact provides interns with an immediate resource for questions/support and ongoing connections with senior residents and a faculty advisor. 2) Fit4Life intervention continued to build/ support colleague relationships through personal fitness. Wellness challenges between trainee years were held to promote physical health per American Heart Association (AHA) exercise guidelines. Three measures — a Fit4Life survey, semi-structured interviews with interns, and Mayo Well-Being Index (MWBI) — were used to evaluate process and outcomes. Results: Fit4Life pre-, during, and postchallenge data showed that less than 20% of internal medicine residents met AHA guidelines: 150 minutes/week of aerobic physical activity. Challenge period results showed a modest but not significant increase in exercise. Average completion rate was 83% of internal medicine residents. Exercise, per AHA recommendations, was paired \u3e50% of time with another activity (eg, watch/listen to television, movies, music, podcasts; connecting with family/friends). RAP intern interviews (13 of 13 [100%]) revealed that 85% were supportive of RAPS and 100% met weekly with RAPS team member(s) at continuity clinic. MWBI scores throughout intervention were well below instruments established at risk level for burnout (5.0), with below burnout scores ranging from 3.1 preintervention (February 2018) to 2.3 postintervention (December 2018). Conclusion: The results of our well-being interventions focused on supportive colleague relationships through RAPS and exercise reveal high participation rates and support but no significant impact on physical or mental health as measured by Fit4Life and MWBI

Activating learners to solicit feedback in 30 minutes or less

Introduction/Background Feedback is an essential component of learning. In medical education, it can come in many forms ranging from clinical quality/patient experience metrics to faculty silence when a learner presents a patient’s differential diagnosis. Yet constructive feedback is usually among the lowest rated items on education/teaching evaluations. Historically the emphasis has been on developing teacher’s ability to give feedback – with teacher’s “pushing” feedback out to the learner who “wrong spots” all the reasons why the feedback is incorrect. Studies indicate that while feedback may be provided, it is often not actionable, lacking specific tactics/strategies for improvement. Consistent with the literature on well-being (competence, perceived autonomy/control, relationship/connection), recent studies shift the emphasis from learner as receiver to learner soliciting feedback. Soliciting feedback can shift the learner’s perspective to asking for feedback focused on achieving one of their valued competency goals with the teacher as an ally. Hypothesis/Aim Statement To evaluate if a brief, evidence-based training session highlighting the why and how of soliciting feedback would result in a commitment by learners to increase the frequency with which they directly asked for feedback. Methods Third year medical students (N=16) and residents from Family Medicine and Ob/Gyn (N=25) attended a 25-30 minute evidence-based session on soliciting feedback. The why, who, what, and how of soliciting feedback was briefly reviewed. Atul Grande’s “Personal Best” article highlighted the need for on-going feedback to optimize performance, be it as a professional athlete or a neurosurgeon. A 4-step model prepared learners to solicit actionable feedback: Ask, Clarify, Consider, Thanks (AC2T) with examples. Participants completed a brief survey which included two items focusing on how often they currently ask for feedback from their clinical teachers/preceptors/attendings and how often they now intended to ask for feedback [6-point scale frequency scale: 1= 0/times; 2= \u3c1/month; 3=1-2/month; 4=1/week; 5=2-3/week; 6= \u3e 5/week]. Results All attendees completed the survey. Results for all attendees (combined) and by group are presented below as means with standard deviation in parentheses. Frequency Solicit Feedback Combined M3 Students Residents How Often Currently Ask for Feedback 4.2 (1.0) 3.8 (0.8) 4.5 (1.1) How Often Intend to Ask for Feedback 5.3 (0.7) 5.5 (0.6) 5.2 (0.7) Commitment to Change (Difference) 1.1 1.7 0.7 Two residents comments highlight that just asking for feedback (e.g., “How am I doing?”) isn’t enough as they recognize the need to focus on all aspects of AC2T model: “Will work on how I ask (specifically) for it.” “I think I’m already pretty good at asking for feedback, but I’d love to have more actionable items!” Conclusions Attendees report that they currently solicit feedback. Post session AC2T they intend to increase the frequency of that solicitation to at least several times/week incorporating key elements to make feedback actionable to achieve their goals. As soliciting feedback is a risk, the intention to increase frequency after a brief training session is promising. Follow-up data will be gathered to determine the degree to which intentions were actualized